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Figure20.2A and 20.2B Involution of super cial tributary varicosities around 15days a er closure of only the proximal segment.
treatment session, we adjust the concentration of sclerosant
to the location and reduced size of these veins. e appropriate concentrations of polidocanol are between 0.18 and
0.37%, injected with a 25-gauge butter y needle; this small
diameter limits the ow of microfoam and is adjusted to
the size of the injected vessels. At this point, the diminished
size of the veins (by involution) allows a larger area to be
treated with the same volume of microfoam. Treatment of
small skin veins (thread veins) requires the use of a special
approach, using ne needles (30 gauge) and lower polidocanol concentrations (0.18%). e lesser foaming capacity
at these low concentrations and the high mechanical stress
su ered by large bubbles when they pass through these ne
needles can cause disruption of the bubbles when homemade foam is used, with most returning to their original
components of gas and liquid. is is a very common cause
A B
Figure20.3A and 20.3B Involution of super cial tributary varicosities
13days a er closure of only the proximal segment.
of complications of the foam treatment of small veins and is
caused by the use of atmospheric nitrogen, with its very low
solubility in blood. Micronization of the bubbles is especially necessary for treating such small vessels, whose therapy
represents the bulk of the practice of many professionals.
TREATMENT EVOLUTION
PROXIMAL SCLEROSIS
A er the re ex vasospasm, (see Figure20.4) and when the
patient leaves the clinic, the blood returns to ll the vessel
sions of the treated vein. Subfascial localization distant from
the skin favors a recovery with moderate or few in ammatory symptoms. In other words, proximity of dilated super cial varicose veins to the skin can produce undesirable
clinical symptoms and increases the risk of pigmentation.
Voluminous super cial varicose veins must be treated with
lower microfoam concentration and only a er the size has
reduced su ciently a er the proximal segment closure. e
aim of this “proximal sclerosis” is not only a more stable
closure of the saphenofemoral junction or of the proximal
source of re ux but rather the involution of distal varicose
veins. In our view, until there is a resolution of the limitations of circumferential compression, this is the most
appropriate approach. In subsequent sessions, we verify by
ultrasound that the treated proximal segment is occluded
and the diameter of the tributary super cial veins, distal
from the closed vein, has decreased signi c a nt l y.
e stable occlusion of the saphenofemoral junction
was a prime objective during the early years of microfoam
sclerotherapy. To mimic surgical ligation and resection
of the saphenofemoral junction, we aimed to close the
168 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
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Figure20.4A and 20.4 B Contact of the sclerosant with the endothelium induces a severe vasospasm, a good and immediate marker of the e ectiveness of
the injection.
junction at the common femoral vein, monitoring its progression toward brosis and resorption. Nowadays, we pay
little attention to the junction, which remains patent, with
no re ux and excellent long-term outcomes. is is similar
to the reported experience with the Vene t procedure and
endovenous laser treatment (EVLT).
S A F E T Y M E A S U R E S I N
MICROFOAM SCLEROTHERAPY
T H E C L O S E D D O O R M A N E U V E R
Table20.1 S A F E T Y M E A S U R E S
Acknowledge limitations of perimetral compression
Previous proximal sclerosis
Limb elevation
Low polidocanol concentration:
GSV:0.7–1%
Involutionated tributaries:0.27–0.37%
Precise lling volume
Nitrogen free gases
Closed-door maneuver
Local compression (leg ulcers)
e most feared complications of sclerotherapy are
intra-arterial injection and deep venous thrombosis (DVT;
Table20.1). e use of color duplex ultrasonography helps
to avoid intra-arterial injection, and injection of the GSV at
the thigh rules out a possible injection of the femoral artery.
At other locations, the use of ultrasound-guided injection
and the excellent reports warning about this issue have
reduced the incidence of this complication, although the
clinician must always be alert to this danger. Routine is a
poor companion in sclerotherapy.
In the sclerotherapy of varicose trunk veins, DVT usually is produced by a coagulation disorder in the patient or by
an error in the administration technique (see Figure20.5).
e most frequent site for this complication is in leg muscle
veins. However, in our experience of treating over 10,000
GSV with microfoam sclerotherapy, we have observed no
occlusion of the common femoral vein. Its high ow dilutes
the sclerosant and reduces the consequences of technical
failures (see Figure 20.6), such as injection of high concentrations or excessive volumes of microfoam for the size
of the vessel treated. Nevertheless, in the beginning when
our technique was not yet fully developed, we performed
slow injections, letting the microfoam pass through the
GSV without taking advantage of the mechanical action
of the pneumatic piston. At that time, we observed several
thromboses in the common femoral caused by bubbles that
oated on the blood when the patient was in the supine
position. ese passed to the femoral vein in “Indian le”
still loaded with sclerosant, contacting its upper endothelial
wall. e limited extent of this thrombosis and its subocclusive nature ensured its rapid lysis in the very few patients
with this complication. e potentially most controversial
points in sclerotherapy of the saphenous re ux are perforating veins with direct connection to the deep venous system
(DVS):femoral, popliteal, and medial gastrocnemius veins
(see Figure. 20.7). ese very common sites of reinjection
carry a high risk of extending the thrombosis of the varicose
vein to a more or less extensive segment of the gastrocnemius vein, which might result in further extension of the
thrombus into the popliteal and super cial femoralveins.
We take two preventive measures to avoid DVT. e
rst one is a dual measure: a reduction in the sclerosant
SCLEROSANTS IN MICROFOAM:ANEW APPROACH IN ANGIOLOGY • 169
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Figure20.5 Postablation saphenous thrombus extension (PASTE) of
common femoral vein with spontaneous thrombolysis. Only two cases
in our experience.
concentration and a strict limitation of the injected volume
to the capacity of the vein to be treated (see Figure20.8).
Injections that exceed this volume and concentrations
greater than 0.37% are errors of technique. e second measure is to close the gastrocnemius vein during and a er the
injection by taking advantage of the muscle function. We
rst con rm by ultrasound that muscle veins are completely
closed when the patient is standing and that they remain so
while the muscle contraction caused by this position persists, with complete closure of the lumen. In supine position,
active dorsal exion of the foot produces a similar result. If
the patient tires, muscle vein occlusion can be achieved by
Figure20.7 is kind of connection (perforating vein) between super cial
and muscular veins increases the risk of DVT. Nothing prevents the injected
sclerosant from exerting its action a little beyond the desired segment.
passive exion, using the hand of the clinician or assistant to
exert dorsal pressure on the foot (see Figure20.9). Active,
voluntary contraction of the muscles is more e ective,
although many patients do not have this ability and must
learn it. We routinely use active dorsal exion during the
injection of varicose leg veins, checking its e ectiveness on
ultrasound. If it is not e ective, another variation of these
maneuvers can be used (see Figure20.10).
We also use these novel and personal “closed-door”
maneuvers during the sclerosis of low perforating veins as a
complementary measure to the pressure exerted on the perforating vein with ngers or ultrasound probe. We must be
100% sure that the sclerosant does not reach the DVS in an
uncontrolled manner. is combination of safety measures
that we have gradually developed and now applied in our
daily practice has led to a dramatic reduction in complications. In our long experience, we have had only 22 cases of
DVT of leg muscle veins among more than 10,000 patients.
Figure20.6 Passage of microbubbles to the femoral vein during injection
of saphenous vein. is situation requires careful duplex ultrasound
monitoring and clearance of the foam particles by foot exion and
extension.
Figure20.8 Perforating veins to the popliteal fossa must be treated while
there is compression at the connection point to minimize the volume of
foam drained into the deep venous system.
170 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
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Figure20.9A and 20.9B Color duplex ultrasonography is used to con rm that active dorsal exion of the foot closes the intramuscular venous segment.
In 10 of these patients, a coagulation disorder was the cause.
A er the introduction of these safety measures we have not
observed a single DVT of muscularveins.
GAS MIXTURE AND BUBBLESIZE
Gas solubility and bubble size are key safety elements of
24
foams. Eckmann
in an “in vivo” model studied the di erences in intravascular dynamics between homemade foams
and Varisolve (the patented microfoam). e author demonstrated that microbubbles do not halt the arteriolar bed ow
while bigger size bubbles produce its complete occlusion.
Even though foam sclerotherapy of varicose veins has
become a widespread procedure, concerns were raised when
ischemic stroke symptoms were reported a er the use of
foam sclerotherapy. e risk for cerebral gas embolism is
particularly increased in patient with cardiac right-to-le
shunt. At the request of the FDA a phaseII clinical trial was
conducted in patients with foramen ovale treated withthe
reformulated Varisolve with very low nitrogen level, demonstrating that this product does not produce any injury
25
to the brain, retina, or heart
as demonstrated by magnetic
resonance imaging with perfusion-weighted images, visual
testing, and marker of myocardial ischemia.
Homemade foams are currently manufactured with
the double syringe technique and a CO
O 2 gas mixture
2
(Table 20.2). However, these foams still contain trace
amounts of nitrogen, high enough to produce symptomatic
gas embolisms. In addition, they lack the key physical characteristics that de ne a goodfoam.
O T H E R S A F E T Y M E A S U R E S : L E G
ELEVATION, ELASTIC LIGATURE,
PRECISE FILLINGVOLUME
Blood is the main adversary of e ective contact between a
known concentration of sclerosant and the endothelium
of large varicose veins. e blood volume can be markedly
reduced by elevating the leg, thereby decreasing the pressure
and facilitating displacement of the blood by the microfoam,
allowing homogeneous contact of the microfoam with the
entire endothelial surface. However, leg elevation does not
halt the proximal ow, and dilution of the sclerosant persists.
Proximal ow can be stopped by placing an elastic ligature
over the internal condyle. is ligature also avoids passage of
the microfoam to varicose leg branches, which are treated at a
later session with microfoam at an appropriate concentration.
A er the procedure, a 23-mmHg compression stocking is
placed, and the patient remains resting for 10 to 15 minutes.
During the resting period, most injected bubbles drain
into the general circulation, some of them are still activated
bubbles. ese are eventually deactivated by xation of the
Figure20.10 Another way to close gastrocnemius veins with the patient
in the supine position is to support the ball of the foot on a at surface
while raising the heel. is maneuver is equivalent to the active
contraction of the muscles while standing.
Table20.2 SOLUBILITY COEFFICIENTS
Oxygen 1
23.75
CO
2
Nitrogen 0.5
Helium 0.35
SCLEROSANTS IN MICROFOAM:ANEW APPROACH IN ANGIOLOGY • 171
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Figure20.11A and 20.11B Extremely voluminous and tortuous varicose veins before and a er treatment (7months).
sclerosant molecules onto the lipid rich membranes of red
blood cells and venous endothelium. At the same time, the
highly soluble gas is dissolved in the blood, a process that is
completed in the lung thanks to its enormous vascular sur-
2
face area of around 150 m
. With foam, it is more critical
than with microfoam to accurately determine the length of
segment to be treated in order to deliver a volume that precisely matches the volume to be lled. It is not enough to let
the foam oat on the blood; a speci c segment must be lled
completely. As mentioned earlier, we test the lling of a vein
segment with microfoam by reaspiration with the syringe,
using the simple method described and reinjecting microfoam if necessary. is assessment of intraluminal content by
aspiration cannot be used in the treatment of incompetent
A B
leg perforating veins when the needle is close to the perforating vein, because the aspirated blood derives from the nearby
DVS, and its lling should not be forced. is situation is
resolved by precisely matching the volume of injected microfoam to the capacity of the vein to be treated.
In comparison to microfoam, for homemade foams
the maximum volume recommended to inject is relatively
small. For this reason, treatment of an extensive venous area
must be performed in more sessions.
e e ective safety measures that we have introduced
make microfoam sclerotherapy the therapeutic procedure
of choice when the anatomical and functional removal of
large and complex pathological varicose veins is indicated
(see Figures20.11 and 20.12).
Figure20.12 Voluminous and complex varicose veins before and a er treatment.
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LONGTERM EVOLUTION
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STABILITY OF OUTCOMES
e Achilles’ heel of surgery is the high recurrence rate of
26,27
varicose veins
together with its aggressive nature and
its incomplete outcomes. In addition, varicose veins o en
reappear in legs that were treated only a few months earlier,
even when all varicose veins were apparently successfully
removed. ese recurrences seem to be caused by the development of varicose veins that were not visible at the time of
treatment but were nevertheless part of the varicose heritage
of the patient. ese incompetent veins take the place of
those that were removed, maintaining hemodynamic continuity to the end vessels in leg muscles and ensuring their
progression.
Besides sclerotherapy with microfoam, we know of no
therapeutic procedure that can remove all types of varicose
veins, in any localization and no matter their size. However,
the disappearance of all varicose veins from a given area does
not mean that total success has been achieved. Final victory
can be claimed only when we can be reasonably sure that we
have also eliminated all veins that may constitute a source
of recurrence. To this end, an exhaustive color duplex ultrasound study is made at subsequent treatment sessions (at
3 to 5months) and we treat all varicose veins revealed in
the leg. Newly formed varicose veins are also identi ed and
treated during follow-up sessions at 6, 9, and 12months.
is active follow-up approach achieves the progressive,
systematic, and complete removal of varicose veins that
could produce a recurrence and whose suppression is the
key to long-term stability of outcomes (Table20.3). ese
goals cannot be attained by surgery or endoluminal techniques when used alone. Varicose disease is considered
an essentially progressive condition. Nevertheless, application of the correct treatment can markedly reduce the
recurrencerate.
Our nal goal is to make our outcomes stable in the
long-term. Our current objectives include to improve the
technique, accelerate the treatment, and make it more comfortable for the patient. e type of compression applied is
of critical importance for comfort. Since we have observed
no bene ts from the application of a strong compression,
we use stockings that exert moderate compression. e
availability of a micronized, homogeneous, and reproducible foam of pharmaceutical grade is crucial, because it will
allow the development of a standardized treatment protocol, facilitating the comparison of outcomes obtained by
di erent groups (Table20.4).
Table20.3 TREATMENT STRATEGY
1° Elimination of existing varicose veins
2° Elimination of varicose heritage
3º 1-year active follow-up guarantee stable outcomes
Table20.4 FUTURE PERSPECTIVES
Pharmaceutical grade microfoam
Standardized technique
OTHER INDICATIONS OF
MICROFOAM
As mentioned before microfoam has been used with
excellent results in patients with varicose leg ulcers and
venous malformations (VM). Our results show that
ultrasound-guided microfoam sclerotherapy is highly e ective in achieving stable healing of venous ulcers, even in old
patients. In addition, we have obtained very good results in
patients with low- ow VM. In patients with medium- to
small-sized VM we were able to completely eliminate the
lesion. In those that presented large VM we achieved a signi cant clinical improvement and reduction in the size of
the malformation. We have never had major complications
in this group of patients.
Although we have limited experience in ultra sound-guided microfoam sclerotherapy of varicoceles, we
obtained very good results and a signi cant improvement
in sperm quality. e therapeutic approach consists in the
injection of 1% polidocanol microfoam with a 21-gauge
needle in the internal spermatic vein at the inguinal canal.
e insertion of the needle and the administration of the
microfoam takes place while the patient performs a Valsalva
maneuver, allowing the microfoam to progress distally from
and proximally to the point of injection, thus preventing
the thrombophlebitis of the pampiniform plexus. In the
follow-up session we con rm the occlusion of the varicocele
by physical examination and color duplex ultrasound.
e e cacy of sclerotherapy with microfoam is now
beyond doubt. It achieves the elimination of all varicose
veins in all patients, with no limitations on the size, location, or morphology of the vessels treated by this method.
R E F E R E N C E S
1. Mollard JM . Chronic venous insu ciency:Prevention and drugless
therapy , Presse Med . 1994 . 23 ( 5 ): 251–258 . Review.
2. Hsu TS , Weiss RA . Foam sclerotherapy:Anew era , Arch Dermatol .
2003 . 139 : 1494–1496 .
3. Cabrera J , Cabrera J Jr. Nuevo método de esclerosis en las varices
tronculares , Patol Vasc . 1995 . 4 : 55–73 .
4. Cabrera Garrido J . Élargissement des limites de la sclérothéra-
pie:Nouveaux produits sclérosants , Phlebologie . 1997 . 50 : 181–188 .
5. Cabrera Garrido J . Los esclerosantes en microespuma contra la
patología venosa , Noticias Med . 1997 . 3 ( 653 ): 12–16 .
6. Cabrera J, Cabrera J Jr, Garcia-Olmedo A . Treatment of varicose
long saphenous veins with sclerosant in microfoam form:Long-term
outcomes , Phlebology . 2000 . 15 : 19–23 .
7. Cabrera J , Cabrera J Jr, García-Olmedo A , Redondo P . Treatment
of venous malformations with sclerosant in microfoam form , Arch
Dermatol . 2003 . 39 : 1409–1416 .
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8. Cabrera J , Redondo P , Becerra A , etal. Ultrasound-guided injection
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of polidocanol microfoam in the management of venous leg ulcers ,
Arch. Dermatol . 2004 . 140 : 667–673 .
9. Bergan JJ , Pascarella L . Severe chronic venous insu ciency:Primary
treatment with sclerofoam , Semin Vasc Surg . 2005 . 18 : 49–56 .
10. Cheng VL , Shortell CK , Bergan JJ . Foam treatment of venous leg
ulcers:Acontinuing experience. In: Bergan JJ , Shortell CK, eds. Venous
Ulcers . Burlington, MA : Elsevier Academic Press. 2007 . 215–226 .
11. Monfreaux A . Traitement sclerosant des troncs sapheniens et leurs
collaterales de gros calibre par la methode MUS , Phlebologie . 1997 .
50 ( 3 ): 351 .
12. Henriet JP . ree years’ experience with polidocanol foam in treatment of reticular veins and varicosities , Phlebologie . 1999 . 52 : 277 .
13. Benigni JP , Sadoun S , irion V, etal. Telangiectasies et varices reticulaires traitement par la mousse d’Aetoxisclerol a 0.25%:Presentation
d’une etude pilote, Phlebologie . 1999 . 52 : 283–290 .
14. Tessari L , Cavezzi A , Frullini A . Preliminary experience with a new
sclerosing foam in the treatment of varicose veins, Dermatol Surg .
2001 . 27 : 58–60 .
15. Wollmann JC . e history of sclerosing foams , Dermatol Surg . 2004 .
30 : 694–703 .
16. Ceulen RP , Sommer A , Vernooy K . Microembolism during foam sclerotherapy of varicose veins , N Engl J Med . 2008.
358 ( 14 ): 1525–1526 .
17. Kas A, Begue M, Ni e C, etal. Cerebellar infarction a er sclerotherapy for leg varicosities , Presse Med . 2000 . 29 ( 35 ): 1935.
18. Forlee MV , Grouden M , Moore DJ , Shanik G . Stroke a er varicose
vein foam injection sclerotherapy , J Vasc Surg . 2006. 43 ( 1 ): 162–164 .
19. Bush , RG , Derrick M, Manjoney D . Major neurological events following foam sclerotherapy , Phlebology. 2008 . 23 : 189–192 .
20. Kritzinger P . Complications of foam sclerotherapy: ree
case presentations , Canad Soc Phlebology Annual Meeting .
Montreal, 2004.
21. Breu FX , Guggenbichler S . European consensus meeting on foam
sclerotherapy , April, 4–6, 2003, Tegernsee, Germany, Dermatol Surg .
2004 . 30 : 709–717 .
22. García Mingo J . Foam medical system, a new technique to treat
Varicose veins with foam. In: Foam sclerotherapy state of the art .
Paris : Editions Phlebologiques Francaises . 2002 . 45–50 .
23. Cabrera J Jr, Garcia-Olmedo MA , Dominguez JM , Mirasol JA .
Microfoam a novel pharmaceutical dosage form for sclerosants.
In: Foam sclerotherapy state of the art . Paris : Editions Phlebologiques
Francaises . 2002 . 17–20 .
24. Eckmann DM , Kobayashi S , Li M . Microvascular embolization following polidocanol microfoam sclerosant administration , Dermatol
Surg . 2005. 31 ( 6 ): 636–643.
25. Regan JD , Gibson KD , Ferris B , et al. Safety of proprietary sclerosant microfoam for saphenous incompetence in patients
with R-to-L shunt: Interim report , J Vasc Interv Radiol . 2008 .
19 (Suppl): S35–S35 .
26. Fischer R , Linde N , Du C , J e a n n er et C , C h a n d l e r J G , S e e b e r P . L a t e
recurrent sapheno-femoral junction re ux a er ligation and stripping of the greater saphenous vein , J Vasc Surg . 2001 . 34 : 236–240 .
27. Stonebridge PA , Chalmers N , Beggs I . Recurrent varicose
veins:Avaricographic analysis leading to a new practical classi cation , Br J Surg . 1995 . 82 : 6 0 .
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ULTRASOUNDGUIDED CATHETER AND FOAM
THERAPY FOR VENOUS INSUFFICIENCY
Nisha Bunke-Paquette , Nicole Loerzel , and John J . Bergan
INTRODUCTION
Duplex ultrasonography is a critical tool for the phlebologist in the evaluation and treatment of venous disorders.
In the initial investigation of primary and recurrent varicose veins, duplex scanning provides direct imaging, localization, and extent of venous re ux with a high sensitivity
(95%) and speci city (100%).
hemodynamic patterns of insu cient veins and anatomical
vein mapping help guide therapeutic options.
guidance and monitoring is crucial to the safety and e cacy of endovenous procedures including thermal ablation, mechanochemical ablation and chemical ablation
techniques. Endovenous thermal therapies for insu cient
veins include radiofrequency ablation (RFA) or endovenous
laser therapy (EVLT). Ultrasonography is used to gain vein
access, introduction of the wire, sheath, catheter, tumescent
application, and in the immediate post-treatment evaluation
for e cacy and complications such as deep venous throm-
6
bosis (DVT).
Mechanochemical ablation involves the use
of a non-thermal, catheter-based sclerosant delivery system.
A Clarivein catheter (ClariVein®, Madison, CT, USA) is
introduced into the targeted vein under ultrasound guidance. e catheter’s rotating wire (mechanical component)
produces endothelial abrasion that is coupled with simultaneous injection of a sclerosant (chemical component). Since
the heating element is absent, tumescent anesthesia is not
required. Endovenous chemical ablation (ECA), also known
as foam sclerotherapy or ultrasound guided foam sclerotherapy (UGFS) uses a foamed sclerosant to induce endothelial
damage and sclerosis. As the name suggests, UGFS requires
the use of ultrasound guidance for targeted sclerofoam treatment of incompetent veins.
component of all endovenous treatment modalities, as well
as for the pre- and post-treatment evaluation. is chapter
describes the role of ultrasound imaging in the endovenous
ablation procedures- techniques and procedural details are
discussed elsewhere in thistext.
1
Precise determination of
2–5
Ultrasound
7
Ultrasonography is an essential
V E N O U S R E F L U X E X A M I N A T I O N
AND VENOUS MAPPING
CONSIDERATIONS
In the pre-treatment assessment of varicose veins, a detailed
duplex ultrasound study of the normal and pathologic
venous anatomy (re ux) is essential. Aclear graphic notation (mapping) of signi cant vein diameters, anomalous
anatomy, super cial venous aneurysms, perforating veins,
presence and extent of re ux should always be recorded
8,9
during the examination (see Figure21.1).
e ultrasound examination is conducted with the
10
patient standing.
is position has been found to dilate
leg veins maximally and challenges vein valves. Sensitivity
and speci city in detecting re ux are increased in examinations performed with the patient standing rather than when
10,11
the patient is supine.
e veins are scanned by moving the probe vertically up
and down along their course. Duplicated segments, sites of
tributary con uence, and large perforating veins and their
deep venous connections are identi ed. eir location measured in centimeters from the oor provides a therapeutic
guide. Measurements from the medial malleolus are not as
precise. Transverse and longitudinal scans combined with
continuous scanning are performed in order to provide
a clear mapping of the venous system. Patency usually is
assessed by compression of the vein with the transducer.
11
Re ux is detected by ow augmentation maneuvers such
as distal compression and release of the thigh and calf or
11
the Valsalva maneuver for only the SFJ.
Automated rapid
in ation/de ation cu s are cumbersome but may be used
for this purpose and o er the advantage of a standardized
12–14
stimulus.
pathologic.
Re ux greater than 500 ms is considered
10,15
e diameter of the SFJ and femoral vein are recorded
for use in judgment for radiofrequency ablation (RFA) and
16–18
endovenous laser treatments (EVLT).
Important infor-
mation also is o ered by the diameters of the GSV at mid
175
Right
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Left
Femoral Vein
SFJ
1.08 cm
GSV
58 cm;
48 cm;
0.36 cm
Figure21.1 e schematic drawing represents patterns of venous insu ciency and vein mapping results. Re uxing veins are added in heavy black lines
selected vein diameters should be included. Location of PVs and aneurysms can be added and distance from the oor indicated.
0.41 cm
34 cm; 0.22 cm
20 cm;
0.4 cm
Vein of Giacomini
22 cm; 0.76 cm
AP 2.2 × LL 1.9 cm
SFJ 1.19 cm
Posterior
Accessory
Venous
Aneurysm
16 cm; 0.6 cm
10 cm; 0.8 cm
Anterior
Accessory
Anterior
Arch
36 cm; 0.65 cm
19 cm; 0.46 cm
“Re-entry”
Sp. J.
0.80 cm
SSV
thigh and distal thigh. e supragenicular, infragenicular,
or immediate subgenicular great saphenous vein (GSV) is
o en the access point for its laser or radiofrequency abla-
18,19
tion.
erefore the depth of the GSV, segments with tortuosity, thrombosis and anatomic variations in these regions
are additional data to be recorded.
Accessory veins by de nition run parallel to the GSV
20
in the thigh (see Figure21.1).
erefore, it is imperative
to map their course accurately and to note their eventual
communication with GSV (see Figure21.1). ey are easily confused with the GSV, especially during continuous
longitudinal scanning, when the saphenous vein appears to
20
leave the saphenous compartment.
Since accessory saphenous veins can also be treated with endovenous thermal
techniques, if re ux is present, their course, distance from
the skin, and length of segment should be documented. e
GSV is then scanned in the leg and the thigh, and tributaries
to the GSV should be noted (see Figure21.1).
e diameters of the popliteal vein and the small saphenous vein (SSV) are recorded, as well as diameters of the
SSV along its course in the leg. Intersaphenous veins should
also be identi ed, and the variability in SSV termination
carefully recorded, especially if it communicates with a
gastrocnemius vein. Ultrasound data regarding an incompetent SSV, such as points of termination, perforating vein
connections, diameter, and proximity to nerves will help
guide thereapeutic options. In transverse section, the sural
nerve can be identi ed within the saphenous compartment.
It lies in close proximity to the SSV in the distal third of the
limb. Consequently, thermal ablation procedures should be
used with caution on the distal leg to minimize the risk of
21
nerve damage.
e venous re ux examination also includes the map-
22
ping of exit and reentry perforating veins (PV).
PV re ux
is detected as outward ow duration greater than 350 ms
on the release phase of ow augmentation maneuver (distal
compression has higher sensitivity in detecting PV re ux).
23
PVs should be accurately identi ed in their di erent loca-
20,24
tance (cm) from the oor in the extended limb.
e minimum requirements for the pre-treatment
duplex ultrasound assessment are described in a Consensus
Document released by the Union Internationale de
25
Phlebologie (UIP), and are summarized in Table21.1.
ULTRASOUND MONITORING
DURING EVLT AND RFA OF THE
GSV ANDSSV
ermal coagulation is caused by the application of electromagnetic energy to the endothelial surface of targeted
19,26,27
veins.
It has been suggested that the coagulation
process in laser treatment is related to the intravascular
vaporization of blood (steam) with intimal denudation
and collagen ber contraction. Vein wall thickening and
rapid reorganization of the vessel to form a brotic cord
26,27
follow.
of the laser or radiofrequency energy application.
techniques have been proven to be safe and e ective.
Occlusion usually is visualized within 10 to 20s
27
ese
28
176 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
Table21.1 PREOPERATIVE DUPLEX IMAGING
https://t.me/med1917
1. Deep veins:assessment for patency and re ux
– common femoral vein (CFV)
– popliteal vein
2. Junctions:assessment for re ux (terminal valve/pre-terminal
valve)
– saphenofemoral junction (SFJ)
– saphenopopliteal junction (SPJ)
3. Main trunks:diameter measurement and assessment of re ux
(in the saphenous compartment):
– great saphenous vein (GSV)
– anterior accessory saphenous vein (AASV)
– posterior accessory saphenous vein (PASV)
– small saphenous vein (SSV)
– thigh extension of SSV/Giacomini vein
4. Tributaries:if incompetent
5. Non-saphenous veins:if incompetent
6. Perforating veins:diameter measurement and assessment of re ux
Adapted from Reference 25.
Percutaneous introduction of the laser or radiofrequency
catheter has made formerly extremely invasive therapy (SFJ
ligation and GSV stripping) more acceptable to the patient
in terms of posttreatment pain, number of cutaneous inci-
17,18
sions, and postprocedural disability.
Before the procedure, it is always recommended to
rescan the patient for better identi cation of the venous
segment to cannulate. is included imaging of the target
vein for access, the saphenofemoral junction, perforators,
tributaries, diameter and treatment length. In this preparatory phase some anatomic landmarks have to be clearly
recognizable:
1. Femoralvein
2. SFJ
Figure21.2 e GSV is cannulated using the Seldinger technique. is
image demonstrates the introduction of a guidewire in longitudinal
view, which is echogenic and can be easily visualized.
Figure21.3 e laser catheter is advanced proximally toward the SFJ.
Position of the laser ber is con rmed by direct visualization of the red
aiming beam through the skin. (Adapted from Navarro L, Min RJ, Boné
C.Endovenous laser:Anew minimally invasive method of treatment
for varicose veins:Preliminary observations using an 810nm diode laser,
Dermatol Surg. 2001. 27 (2):117).
3. Saphenous compartment
4. GSV
5. Small saphenous junctional anatomy
Introduction of the introducer sheath is performed
percutaneously using the Seldinger technique. e supragenicular saphenous vein is usually the access point of
choice. A guidewire is readily visible on ultrasound (see
19
Figure21.2).
e intraluminal position of the sheath is
ascertained by aspiration of nonpulsatile venous blood. e
sheathed laser ber or a ClosureFast catheter is advanced to
a point just distal to the entrance of the epigastric vein.
Position of the laser ber is con rmed by direct visualization of the red aiming beam and that of the ClosureFast
catheter by ultrasound (see Figures21.3 and 21.4).
ULTRASOUNDGUIDED CATHETER AND FOAM THERAPY FOR VENOUS INSUFFICIENCY • 177
19
18
Figure21.4 Position of the radiofrequency catheter is monitored by
ultrasound visualization.
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